Clinical Question: Can stable patients presenting to the emergency department with blunt abdominal trauma be managed safely without a CT scan?

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You are working in a rural Emergency Department (ED). You assess a 25-year-old male patient who crashed his car into a tree. Vitals are normal and GCS is 15. Airway is patent and protected. There is bilateral chest rise, no abdominal tenderness or seatbelt sign. Pelvis is stable, and you notice some swelling over his right wrist.

What is Blunt Abdominal Trauma?

Blunt abdominal trauma is an injury to the abdomen without an open wound. In Canada, this most commonly occurs with motor vehicle collisions or falls.​1​ The organ most commonly affected is the spleen, followed by the liver.​2​

Current Management of Blunt Abdominal Trauma

For any trauma, start by getting a set of vitals and completing a primary survey following an airway, breathing, circulation, disability, and exposure (ABCDEs) approach.

X-rays, labs, an ECG and point of care ultrasound (POCUS) are useful adjuncts while the primary survey is taking place. POCUS is one of the most important investigations, as it can help identify free fluid in the abdomen.​3​ After completing the primary survey and addressing immediate life-threatening injuries, we would move onto a secondary survey which often includes a CT scan…if this is available at your center!

To learn more about the POCUS/FAST exam check out this article: What is the role of the FAST exam for blunt abdominal trauma?

What if you don’t have access to a CT scanner?  

CT scans are not always available in rural settings. A study examining a random sample of Canadian EDs found that only 20% had access to a CT scanner.​4​ What do we do in this situation?

Rely on your clinical exam! Based on the EAST trauma guidelines, stable blunt abdominal trauma patients can be assessed with serial physical exams.​5​ If abdominal tenderness, distention, rebound tenderness and/or the “seat belt sign” are elicited on physical exam, further imaging is recommended.​6​ POCUS is a great resource for identifying free fluid in the abdomen and is becoming more accessible in rural EDs.​7​ If the patient remains stable and no free fluid is identified, the patient can continue to be observed with serial physical exams. If free fluid is identified think about transfer to a center with a CT scanner and surgeon.

Back to case

ABCDE’s are intact and no concerning features are found on his labs or ECG. The patient is in a monitored bed and vitals remain stable. No free fluid is identified on POCUS.

He is found to have a right distal radius fracture which is reduced and casted. The patient is admitted, and a clinical examination of his abdomen is repeated every 2 hours.​8​ His abdomen remains benign, and after 24 hours of monitoring is discharged home.

Bottom Line

When it comes to managing blunt abdominal trauma in stable patients, let your clinical exam be your guide. Patients who remain hemodynamically stable with no concerning features on physical exam can be safely managed with careful observation. POCUS is helpful in identifying intra-abdominal injury and is a great resource both as an adjunct and in the absence of a CT scanner.

Copyedited by Casey Jones (@CaseyMAJones).

References

  1. 1.
    Haas B, Poon V, Waller B, Sidhom P, Fortin CM. National Trauma Registry 2011 Report: Hospitalizations for Major Injury in Canada, 2008–2009 Data. Canadian Institute of Health Information; 2011:1-114. https://secure.cihi.ca/free_products/NTR_CDS_2008_2009_Annual_Report.pdf
  2. 2.
    Nadir NA. Abdominal Trauma. Clerkship Directors in Emergency Medicine. Published 2019. Accessed April 13, 2022. https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-trauma/abdominal-trama
  3. 3.
    Jansen J, Yule S, Loudon M. Investigation of blunt abdominal trauma. BMJ. 2008;336(7650):938-942. doi:10.1136/bmj.39534.686192.80
  4. 4.
    Fleet R, Poitras J, Maltais-Giguère J, Villa J, Archambault P. A descriptive study of access to services in a random sample of Canadian rural emergency departments. BMJ Open. Published online November 2013:e003876. doi:10.1136/bmjopen-2013-003876
  5. 5.
    Hoff WS, Holevar M, Nagy KK, et al. Practice Management Guidelines for the Evaluation of Blunt Abdominal Trauma: The EAST Practice Management Guidelines Work Group. The Journal of Trauma: Injury, Infection, and Critical Care. Published online September 2002:602-615. doi:10.1097/00005373-200209000-00038
  6. 6.
    Simel DL. Does This Adult Patient Have a Blunt Intra-abdominal Injury? JAMA. Published online April 11, 2012:1517. doi:10.1001/jama.2012.422
  7. 7.
    Léger P, Fleet R, Giguère JM, et al. A majority of rural emergency departments in the province of Quebec use point-of-care ultrasound: a cross-sectional survey. BMC Emerg Med. Published online December 2015. doi:10.1186/s12873-015-0063-0
  8. 8.
    Cowell VL, Ciraulo D, Gabram S, et al. Trauma 24-Hour Observation Critical Path. The Journal of Trauma: Injury, Infection, and Critical Care. Published online July 1998:147-150. doi:10.1097/00005373-199807000-00030

Reviewing with the staff

Blunt abdominal trauma (BAT) is one of the most common presentations of trauma. The severity of BAT can range from mild to life-threatening and regardless of where you work, be it at a rural hospital or at a trauma centre, BAT patients can be challenging to diagnose and manage. This article discusses the approach to BAT patients and reviews the importance of serial physical examinations and point of care ultrasound. Definitely an important read for emergency medicine trainees!

Dr. Steve Lin
Emergency physician, Trauma Team Leader and scientist, St. Michael\'s Hospital
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Kylie Suwary

Kylie Suwary

Kylie is a third-year medical student at Western University. In addition to emergency medicine, her interests include medical education, addictions medicine and simulation. In her free time, she enjoys drinking copious amounts of coffee, exploring new restaurants and cycling.
Jamie Riggs

Jamie Riggs

Jamie is an emergency medicine resident at the University of Toronto. He is interested in trauma, medical education and prehospital medicine. Outside of the hospital find him on his bike or hunting for sushi and coffee.
Jamie Riggs
- 4 days ago